Lockout/Tagout Compliance: Group Lockout and Shift Changes

March 1, 2010
Part 2 of our three-part series about lockout/tagout compliance examines the challenge of shift changes to safety. (Read part 1 here)

It's 5:10 a.m. and Glenwood (“Woody” as he is known around the shop) was wrapping up his third-shift work on a case packer. His task that night was to replace the main drive motor and gear reducer. Normally, he has help with this task, but recent downsizing efforts left resources stretched thin, leaving him to work alone.

Woody has 33 years of experience and knows a thing or two about how to be safe while he is working on equipment. In fact, he was on site when someone was killed last year because they didn't properly lock out the equipment. On this particular morning, Woody followed all his training to lock out the equipment. He followed the equipment-specific lockout/tagout procedure, applied his personal locks to each isolation point and even ensured all the residual energy was dissipated before the service work began.

After running into a few snags during the service, he knew that he wasn't going to be completed before the end of his shift. The company had a strict no overtime policy, so he thought it would be best to find a good stopping point and hand the task off to the next maintenance crew. Woody removed all his locks for his personal protection and proceeded to the break room to meet with the next maintenance tech who would inherit the task.

As Woody headed into the break room, he heard a blood-curdling scream come from the shop floor. He knew something was wrong so he hurried back to see the case packer operator lying unconscious next to the equipment and bleeding severely. Woody wondered what went wrong, because he had followed all of his training and duties.

What did go wrong? Was this the company's fault, Woody's fault or the operator's fault? Actually, the problem is a combination of all three. OSHA only will penalize the employer, as the agency does not issue citations to the workers. After an investigation, it was determined that the operator tried to turn on the case packer to see if it was operating properly so he could get the line running as he was instructed by his manager. The manager didn't know that the case packer still was in service because it was supposed to be completed by that time. It was determined that this scenario would have been prevented with proper training, utilization of proper shift change procedures and periodic auditing of the lockout/tagout program to proactively catch issues like this.

OSHA regulation 1910.147 part (f) exists to prevent this exact scenario from occurring. Lockout/tagout shift change rules are not just for the authorized employee's protection; they exist to protect any worker from injury or death due to inadvertent re-energization of the equipment.


1910.147(f)(4) states: “Specific procedures shall be utilized during shift or personnel changes to ensure the continuity of lockout or tagout protection…” When Woody removed his personal locks and left the equipment unattended, he unknowingly broke this rule and an operator severely was injured and nearly died.

The easiest way to understand the lockout/tagout standard's stance on group lockout and shift changes is to understand (and I mean really understand) the intent of the section, which is: To prevent unexpected start up of equipment or energy to protect employees from harm.

There are 1,001 ways to do this, but all of the correct ways should utilize a physical device to prevent accidental re-energization (read: lock and tag) that prevents accidental restarting of equipment should communication breakdown occur.

Based on what we know from this accident, the authorized employee should have used a shift change lock to which only authorized employees have access. This clearly labeled shift change lock would have prevented unexpected start up of the equipment until the next authorized employee was ready to start his task. The next employee would install his personal lock on the equipment and remove the shift change lock before beginning service work. It's important to train employees to never use shift changes locks for personal protection, because others have the ability to remove them.


I've heard that some companies use several temporary workers to inspect and maintain their equipment while it's locked out. Their previous method was to have their authorized employee lock out the equipment properly, then record the names of those working on the equipment to ensure they are all safely positioned when it's time to turn the equipment back on. At first glance, this seems like a good system, but what happens when someone starts working on the equipment without signing on? What happens when the authorized employee loses the sheet of names or forgets to put one name on the sheet? Now those employees are unprotected and an accident may occur.

1910.147(f)(3)(ii)(D) states: “Each authorized employee shall affix a personal lockout or tagout device to the group lockout device, group lockbox or comparable mechanism when he or she begins work, and shall remove those devices when he or she stops working on the machine or equipment being serviced or maintained.”

To allow temporary workers to work on equipment that is locked out, one option would be to utilize a group lock box. When the authorized employee locks out all of the energy sources, he will place the keys to these locks inside the lock box. When the temporary employees are servicing the equipment, they must place their lock on the lock box to ensure the equipment cannot be started until they remove their lock. This system also should be supplemented with a brief, on-floor training that gives an overview of the equipment they are working on, hazards related to that equipment and process and energy sources that are involved. Each worker (temporary or not) has the right to inspect all the energy sources to ensure they properly are locked out before they put their lock on to service the equipment.

If you think you have a unique process to which lockout/tagout doesn't apply, remember this: lockout/tagout currently is the No. 1 most-cited OSHA regulation in the manufacturing industry. Many companies are surprised when they get hit with a six- or seven-figure lockout/tagout violation, especially when they thought they were in compliance. For companies that knowingly and willfully break the law, OSHA can and will prosecute these infractions as felonies and the punishment can include prison time.

Complying with lockout isn't easy, but once you're in compliance, it's easy to maintain. In fact, some industries may boost productivity by complying, which helps justify upgrading to a modern graphical approach that utilizes digital pictures and color coded steps to help make lockout easy.

Jimi Michalscheck is the vice president and co-owner of ESC Services Inc., an engineering firm that specializes in lockout/tagout compliance. ESC has helped more than 250 companies around the United States achieve and maintain lockout/tagout compliance. To contact ESC, visit their website or call ESC directly at 262-939-4825.

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